Prestigious Personal Home Care Services

Prestigious Personal Home Care Services

APPLICATION FOR EMPLOYMENT
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
SSN
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you legally authorized to work in the United States?

YesNo
Are you at least 18 years old?

YesNo
Active CPR/First Aid Certification:

YesNo
Date Received Certification:
Special skills, certificates, awards or courses:
High School   Type a label
City/State   Type a label
Dates   Type a label

Vocational School   Type a label
City/State   Type a label
Dates   Type a label

College   Type a label
City/State   Type a label
Dates   Type a label

Course(s) of Study   Type a label
Some of our clients speak languages other than English. Are you fluent in any languages other thanEnglish?

YesNo
If Yes (please list)
Do you have any other training, experience, skills, qualifications or experiences which make you especially suited for employment as a senior caregiver?
Any days and times not available to work:
Days and Times you are available to work:
Can you be called at the last minute for emergency assignments:

YesNo
*EMERGENCY CONTACT
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
If applying for a position requiring company driving, do you have a valid Driver’s License?

YesNo
Can you provide proof of current auto insurance?

YesNo
Have you ever been convicted of a criminal offense?

YesNo
If yes, please state the nature of the crime (s), when and where you were convicted, and the disposition of the case:
Other name(s) under which employment may be verified:
Are you able to perform the essential functions of the job for which you are applying, either with orwithout reasonable accommodation?

YesNo
If no, describe the functions that cannot be performed:
WORK EXPERIENCE:
Discuss any training or related experience working with the elderly that you have had:
Company or Employer #1:
Phone Number
Please enter a valid phone number.
Address:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Duties:
Supervisor:
Reason Left:
May we contact:

YesNo
Starting Salary:
Ending Salary:
Company or Employer #2:
Phone Number
Please enter a valid phone number.
Address:
Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Duties:
Supervisor:
Reason Left:
May we contact:

YesNo
Starting Salary:
Ending Salary:
Personal References
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Known for how many years:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship:
Known for how many years:
CERTIFICATION AND RELEASE

I certify that I have read and understand the application note onpage one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicledriving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature

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Date

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